Prof. Joseph Levine

Senior Psychiatrist




Session 9: Our patients as our teachers

By Prof. Levine & Dr. Salganik

The case of Shlomit…

Our patients are often our teachers for understanding the inner worlds associated with patients and psychopathology.

Thus the "laboratory" for the development of the theoretical method for RGFT was the treatment room or actually the treatment process and its content.

Hence, on the one hand the discourse of a particular patient may have a potential to teach us about the development of a particular illness or mental condition and even ways to deal with them, and on the other hand, the therapist often has a thought or idea about the new ways of doing it within his/her treatment room but also in the wards of a psychiatric hospital.

This was, for example, the way the “Trigger Event Analysis” (TEA) the method analysing triggers or events that contribute to the onset of a mental condition or mental psychopathology, has been developed. The idea of the TEA emerged following the story of a patient in the psychogeriatric ward, a subdivision engineer whose daughter has been killed in a car accident, am event that affected him much less than his transfer to another job position without any change in his working conditions. This last event was perceived by him as a terrible humiliation and he committed a suicide attempt by jumping from the 3rd floor. This unfortunate event demonstrated clearly the individual relevance of traumas and is inconsistent with the accepted scale known as Stress Inventory by Holmes & Rahe.

We would like to bring this time a summary of the long treatment in which a bipolar (manic-depressive) patient was accompanied by one of us [JL] for about two decades.

During the treatment, there have been many issues that were discussed, including medication. But here we will focus on just one aspect of the treatment and that is the treatment using guided imagery.

This patient had previously been treated with psychoanalytical therapy, when she came to JL she asked to be treated with guided imagery but without a guidance of the therapist (actually, the therapist’s guidance during the guided imagery sessions was minimal).

At first, she was told to slowly and gradually close her eyes and let her body be relaxed.

Then she was told: "Let the imagination lead you as you wish and I [the therapist] will count slowly until 30”.

This state lasted for about 25 to 30 minutes.

Consequently, a series of alternating images appeared in her imagination while none of them was induced by the therapist.

Below, of course with her consent, we will present verbatim what shlomit [pseudonym] wrote, omitting identifying details:

Guided imagery over the years.

Preliminary note: All images are different and varied expressions of the psychic forces within me.

First period – the menacing snake.

the menacing snake

During the first period of treatment and for a long period of time I saw in any guided imagery a large and frightening menacing snake. It was a constant guided imagery that repeated itself in the same way. I would wake up from this imagination always scared and frightened”.

The snake – expresses manic depression. The difference between the snake and any other threatening animal like a lion, is that in the other animals the danger is in front of you, you are aware of the danger, see it approaching and can try to escape from it. A snake however is an animal of such a kind, that even before you see and recognize the danger, the snake has already bitten you. Thus, the manic depression is that a patient may be deeply within the illness, the problem however is that the sick person himself is unaware of the danger and distortions of his/her thinking. The illness attacks and the danger it brings with it, appear when there is no longer conscious awareness and logical thinking and patient’s ability to cope with it by himself. Like biting by the snake, first comes an attack and only at a later stage comes recognizing the intensity of the problem.

Second period – the vegetation.

the vegetation

The vegetation period as a whole, expresses a process of beginning growth and change and is also the end of the process – what will come out of me is a fruit basket – an expression for success in various fields.

Period of plants and trees without fruit – After the period of the snake I began to see weeds and idle trees.

When I awoke from the guided imagery of this period I realized that there is a slow process of progress but I was disappointed that there is no fruit.

Period of trees with fruit – I saw various fruit trees of different types. When I awoke from these fantasies I was glad that I was finally able to see that I too would finally bear fruit. "Something came out of me."

One large tree that grows on top of each other in different types of fruit – the vegetation period finally came down to a specific guided imagery in which I saw one large tree on which mangoes, watermelons, melons, oranges, peaches, apples and so on grow together. I remember this resemblance in a special way, it was a particularly rainy day (in reality) and the appearance of this tree in the imagination accompanied by the sounds of the rain from outside was very realistic and significant for me. This imagination of course made me very happy and accompanied me throughout the years in the subconscious that very good things will come out of me too.

Third period – the animals.

During the period of the animals, various animals appeared in guided imagery, each of which represented a different mental trait. A period of guided imagery while seeing different animals lasted a long period of several years.

The different animals and psychic powers they represent:

Feathered chick – a small and weak, scared chick. I remember a guided imagery that I saw the weak chick, and it’s hard for it to be in an empty boxing ring. The chick expresses the weaknesses, anxieties and fears.

Lioness – a strong and powerful lioness. I remember a guided imagery that once the lioness in me fought with a lion and defeated him. The lioness expresses extraordinary power.

The wolf – a wolf whose colors were white, gray and black. A beautiful and very impressive animal. The wolf expresses wisdom in my eyes.

Dolphin – the dolphin has appeared many times as a kind and happy animal. To me, a dolphin also expresses wisdom.

Fish – sometimes various edible fish swam next to the dolphin. Fish expresses the blessing on Rosh Hashanah that we will be "head and not tail." Aspiration for progress.

Turtle – expresses the carrying of the past on its top. That the past is the burden of my life in the present as well.

Dog – expresses love and human warmth.

Elephant – a large and impressive male elephant. Expresses wisdom.

Bear – A good big bear envelops me with love and warmth. The bear expresses warmth and motherly love. To this day following this beloved character bears are animals that I love very much.

The bear expresses warmth and motherly love

Forth period – human figures of the male gender:

Male human figures are figures who express the transition to a period of more successful coping with the disease and a better ability to "look the disease in the eye." These characters have a closeness to me as a human being but they are also different from me because they are not female characters.

From this period I clearly remember only three figures:

Beach boy character – a young man who lives in a kind of holiday village on beaches in the style of the Hawaiian beaches in the movies. He is a guy with long and cute hair wearing holiday clothes. The figure and how it looked is very reminiscent of my younger brother as he would have looked at 20 (my brother at that age also had long hair). This brother has always been my special favorite even when I was a young girl I took care of him. I highly appreciate him today even to the point of admiring certain of his character traits. Important detail to note I was diagnosed as a manic depressive at the age of 20.

This character expresses the mind – at that time I was surprised on the one hand that the mind is represented by a young character and not a smart old man for example. But on the other hand it befits the nature of the disease which sometimes strays from my rational mind.

Businessman – looks like a very wealthy businessman with a very luxurious watch on his hand dressed in luxury suits. The character would advise me on how to act and succeed. Spoke wisely.

A very repulsive male figure – a figure with a distorted face and reports with a Hitler hairstyle. I really hated this character it caused me a lot of rejection.

Fifth period – female characters who are not myself:

Different female characters that are not me – I only remember two characters:

The crazy character – scary, threatening.

Businesswoman figure – a very successful businesswoman, running the world.

Sixth period – guided imagery of different characters who are myself in a variety of different roles:

During this period I see myself in different roles and in different images. This period lasted for a long time.

The characters of me in the various aspects:

I'm crazy – this character scares the rest of the characters, is threatening, violent and aggressive. Sometimes I saw her sitting in jail. Of course, this character expresses the disease and its severe attacks.

I'm the lawyer – dressed like a lawyer in the movies. She is dressed like a lawyer but hates the profession. Details below. I am a lawyer by education who hated the profession and suffered greatly during the specialization period.

Me as a writer – I appear as a female character from the thirties of the twentieth century. The character is very confident in herself smoking cigarettes with a mouthpiece and Kara hairstyle, dressed at the top of the fashion order of that period. During these years I was consciously not confident in myself, I never smoked but I had a similar hairstyle to the character's hairstyle when I was a child in kindergarten. My late father always wanted me to write books.

Me as a 19th century character- I wear fancy 19th century dresses and that century hairstyle. She is a very elegant female figure. I remember a guided imagery that she walks along the river and has a picnic on a sunny day. This character has appeared several times. Note: I really like these Victorian dolls, but I never bought one. This character is the only character I do not know what she represents within me.

I am a lecturer – I lecture in a hall inside the academy. The character is dressed elegantly and neatly, showing self-confidence. This character is a lecturer in academia. Sometimes I saw myself as both a lecturer and a student of my own. Sometimes I, the student, did not understand what I was talking about. This character has appeared numerous times. In reality I have degrees in law, education, political science and Jewish philosophy and I have a mediator certificate from the Bar Association. I also taught law students for a living and in the distant past I considered lecturing privately in various fields such as creative thinking.

I am a princess – sometimes a character appeared who dressed like a princess and had a crown. Her dress and shoes were silver. Silver color represents the degree of grace in the world according to Kabbalah.

Lately I have been appearing in guided imagery as I am in reality and not a character I play.

I'm a normal lunatic – perhaps the most important character of all the characters. I myself appear and say that I am the crazy character but I am focused, talking rationally and being asked I give myself very smart advices. Surprising how clever this character is. I say I'm crazy but in fact the expression of it lately is an expression of extraordinary wisdom.

Guided imagery descriptions that are landmarks of change over the years:

* Guided imagery in which I talked to the snake:

It was a guided imagery that after a long time that I was just scared of the snake and was terrified of it I saw the big and menacing snake and started communicating with it and talking to it. This was the first time I had taken an active action against the snake. The content of the things I said to the snake I do not remember.

* Guided imagery in which the snake did not appear:

For years I waited for the moment when I would wake up from a guided imagery and where the snake itself would not appear, I do not remember the content of this guided imagery but I certainly remember the sense of relief that arose after not seeing any snake in my guided imagery.

* The tree with the multiplicity of different fruits grows on it at the same time:

Detailed above

* Guided imagery in which I cried with real tears:

I remember a guided imagery which content I don’t remember where I cried with real tears, but I remember the feelings of sadness and distress and longing that I awoke with.

* Guided Imagery Law Office:

It was a guided imagery after obtaining the license of a lawyer in which I considered whether to engage in this profession. I saw myself dressed in elegant lawyer clothes walking into a very luxurious office. I saw myself sitting in the office and unable to function, I hated it very much. I could not find any area in law that I would connect to as for example, dealing with contracts. The message in this imagination was very clear and sharp that I really but really do not want to engage in this profession. In reality, I hated very much the internship and suffered from it.

* Guided imagery that I take care of people:

In this imagination I distanced myself for the first time from being a patient and supported person and switched to a character who cares for two people. A very important landmark in terms of a message.

* Guided Imagery with Praying Mantis:

In this imagination I saw a mantis dressed in a suit and when I asked it what to do in life, it replied to me “be a jewelry designer”. The jewelry motif has appeared over the years, sometimes gold rings and sometimes cheap jewelry. In reality I have an online jewelry store.

* Guided Imagery – Encounter with Demons:

I see myself riding with a cart and horses with two of my brothers. At a certain place in my hometown I see a large sinkhole opening up. I enter the sinkhole alone and I see scary demons laughing with strange voices. Then I see the King of Demons, I manage to face the King of Demons and imprison him in a cage (I do not remember the way I overcame it, only that I finally won). In my interpretation this resemblance represents the process of overcoming the inner demons within me.

* Guided imagery in which I pray to the Creator of the World:

In this imagination I pray to the Blessed One from the bottom of my heart for me and my family. The combination of faith and relaxation in the imagination is a strong emotional combination. I get up very encouraged from this guided imagery. This imagery has appeared many times over the years.

* Meeting with my late grandparents:

In a number of guided imagery I saw my grandparents, be their memory blessed. I saw myself begging them to give me something and at the end I get a pot of avocado tree with three fruits. My grandparents had a huge avocado tree in the yard. I was my grandfather's most beloved granddaughter of all the grandchildren it’s from him that I inherited manic depression. This imagery indicates continuity, I was very moved by this imagery and it made me stronger.

* Guided imagery of my late father:

In this imagery I saw the father, be his memory blessed, greets me and tells me that he is very pleased with me. I am in fact in the first year of mourning for my father and have been waiting a long time to meet him in guided imagery. The message that my father sees me from the world of truth and is pleased with me, this imagination moved me a lot and strengthened me.

* My encounter with myself when I'm 19:

In this imagination I see myself present-day entering my workplace at the age of 19 which was a kindergarten in my hometown (the place appears in the imagination as it was in reality). I say to myself “young woman I came to pick you up from here”. We leave the garden and walk away from it. My interpretation of this imagery is that unlike all of my family, I never wanted to be hired and they would dictate to me what to do and I went back to my first job as an employee to get myself out of there.

* My encounter with myself when I’m 16:

I see myself nowadays in a holiday village on the shores of the Sea of ​​Galilee walking with a dog. I meet myself as I am photographed at the age of 16 in a picture where I am on a trip on a pier (in reality – I have a picture in which I am photographed on a trip on a pier). The contemporary self tells the 16-year-old “I am your future”. She tells me she does not recognize me, I try to explain that we have a future relationship, she looks at me in strangeness and tells me you have a dog I have a rhino. For her, 16-year-old, a dog is less good than her rhino. We enter the building and then I go out of it as the contemporary me, I say “I also have a rhino” and outside, next to the door, there is a large and impressive rhino that belongs to present-day Shlomit.

* Strange characters that appeared in guided imagery:

Fish in suits

Dogs sit on chairs like humans around a fancy dining table and study Torah

Oranges – In my opinion, an acronym (in Hebrew) for earning (golden apple).

Radishes – The color of the vegetable is important. Red – symbolizes the degree of justice in the world. White – symbolizes the degree of grace in the world according to Kabbalah.

An overview of the emotional and mental processes that appear in guided imagery throughout the years:

A. Ability to approach emotionally and mentally the difficult aspects of the disease. As the periods have changed and characters have emerged that are as close to the self as I am in reality so there is an ability to examine the disease in a less frightening and anxious way.

B. In retrospective analysis (except for the period of the snake – which as mentioned was particularly long) there appear, throughout the different periods, two completely diametrically oposite images of the psychic forces. On the one hand crazy-frighteningly violent and weak characters. On the other hand, there are also images of strong and very smart characters, for example the lioness and the wolf or a businesswoman. I used to think that the disease made me a very weak and dependent person, but in retrospect I also had quite a few psychic powers within the subconscious that express real power and wisdom. In my opinion, the powerful unconscious psychic forces were a mental framework for insanity.

C. A process that stands out over the years is a process of strengthening and better ability to trust myself. I work in a creative and constructing world. A process of strengthening self-confidence and the ability to trust oneself despite the history of disease attacks and the not-so-simple illness.

Shlomit’s remarks were quoted here exactly as she wrote them and without any omissions other than deleting identifying details. Much can be learned from her writing.

But we want to address here one aspect that her writing exemplifies, and that is:

The crucial difference between internalized and metaphorical characters:

This particular patient because of her pronounced imaginative ability allows us to demonstrate how to draw a decisive line between the internalized images and images that can be evoked through imagination but are not internalized.

We would like to further elaborate on it a bit. As we can see, the patient arises various images during her guided imaginary sessions, some of them are persons from her known environment (lawyers, business people), some are her relatives (her father, her grandfather, etc), some of them are her herself at different ages and different mental states. What is common among all these images is that they can be traced down to some actual persons from her past.

Apart of these characters that represent persons she actually encountered in her life, there are others, both of human and non-human origin: a man in dark clothes with a threatening face, a young boy with a long hair somewhat resembling her younger brother, a wolf, an elephant, etc. If we try to find their common denominator we could discover that all of them have some metaphorical meaning, in other words, they represent some abstract idea and are not fully developed and consolidative characters.

Here we would like to underline the crucial difference between internalized and metaphorical characters:

Internalized images or characters are formed as a result of the internalization of various features of the really existing living beings both as individuals or groups (for us, humans, in their overwhelming part of human origin), This internalization incorporates behavioral, emotional characteristics, for humans this comprises also specific for a person or group attitudes. The whole process is mostly based on modeling and social influence and does not necessarily require language as a prerequisite.

On the contrary, metaphorical images or characters are intrinsically interconnected with the language and usually symbolize some abstract concept. For example, Freddy Kruger can symbolize cruelty, a lion can symbolize strength, an owl – wisdom, a dog – loyalty, etc.

It’s important to emphasize that in this regard, all of the mentioned above are generalizations and not concrete subjects.

But if we are talking of a particular person or animal that has some personal significance for us then we can assume that it may be turned into internalized image. Once again, the key point here is that it should be some tangible subject charged with personal significance for us.

To summarize, internalized characters are always of complex nature and have deep personal significance, whereas metaphorical characters originate in subculture, express just one or few abstract concepts, are common for a large group of people, and have usually very little or no personal significance.

See you in the next session,

Dr. Igor Salganik & Prof. Joseph Levin

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